Name of Child
Address
City, State, Zip
Child's Date of Birth
Child's Gender/Pronouns
Child's Age
Child's School
Child's Grade as of August 2024
Camp Attending
June 17-21: World Dance
June 24-28 West African Culture: Drumming, Dance, Clothing & Food
July 8-12: Blues
July 15-19: LEAF International Haiti
July 22-25: Making a Music Video: Songwriting, Recording, and Filmmaking
July 29 - August 2: Stop Motion Animation
August 12-15: Songwriting and Recording
August 19-23: World Changing Visual Arts
T-Shirt Size
Youth-Small
Youth-Medium
Youth-Large
Youth-X-Large
Adult-Small
Adult-Medium
Adult-Large
Adult-X-Large
Parent/Guardian Name
Name on Credit/Debit Card used for Summer Camp purchase
Parent/Guardian Phone
Parent/Guardian Alternate Phone
Work Phone
Parent/Guardian Email
Employer
Hours
Parent/Guardian Name
Parent/Guardian Phone
Parent/Guardian Alternate Phone
Work Phone
Parent/Guardian Email
Employer
Hours
Name of Child's doctor
Doctor's Address
Doctor's Phone
Name of Child's Dentist
Dentist Address
Dentist Phone
Hospital Preference
Please list any allergies, dietary restictions, or health concerns we should be aware of for your child.
Additional Emergency Contact Name
Additional Emergency Contact Phone
Additional Emergency Contact Relationship
Additional Emergency Contact Name
Additional Emergency Contact Phone
Additional Emergency Contact Relationship
Additional Emergency Contact Name
Additional Emergency Contact Phone
Additional Emergency Contact Relationship
Additional Pick Up Person Name
Additional Pick Up Person Phone
Additional Pick Up Person Relationship
Additional Pick Up Person Name
Additional Pick Up Person Phone
Additional Pick Up Person Relationship
Additional Pick Up Person Name
Additional Pick Up Person Phone
Additional Pick Up Person Relationship
Participation Acceptance
I hereby give permission to LEAF Global Arts for my child to do each of the following:
● Participate in a walking trip or to be transported in a vehicle for a field trip.
● Participate in developmentally appropriate, supervised activities outside of fenced playground / play area.
● I certify that I have read, understand, and accept the following representation, stipulations and hereby waive for
myself, my personal representative, heirs and next of kin, and on behalf of my child: ALL CLAIMS, WHICH I MIGHT HAVE
AGAINST LEAF, ANY OTHER PROVIDERS OF FACILITIES AND ANY OF THEM IN COMBINATION, and their officers, directors, agents,
employees and contractors, for injury, accident, illness, property damage, death or other occurrence arising in any manner
whatsoever out of my participation in activities sponsored by LEAF Global Arts. FURTHERMORE, I agree to indemnify, save and
hold harmless LEAF global Arts from any and all loss, costs, damages, expenses, and attorney’s fees arising out of my
participation, or the participation of persons who accompany me, in LEAF Summer Camp related activities.
Submit
